Medical Consultation Form
First & Last Names*
Date of Birth*
Address & best contact number*
Doctor's Name & Address*
Do you have, or have you had any of the conditions listed below*
Pacemaker or pacemaker leads
Phlebititis or Thrombosis
Inflammation, Infection or Tumour in any area
Contact Dermatitis or any other skin disease
Recent Scar Tissue
Metal Implants, screws or prothesis
Allergy to rubber, copper or other metals
Lack of normal skin sensation
High/Low blood pressure
Any condition under medical care
Are you pregnant?
Are you taking any anti-depressants?
Are you taking any muscle relaxants?
If the answer to any of the above is yes, please provide further information
Please write your first and last name and today’s date if you agree to the following: I certify that the statements I have made are true and correct, and that I, having been advised and fully informed concerning the nature of the treatment process proposed to be administered, hereby authorise and direct you to administer such processes and perform such procedures as may be deemed necessary or advisable. My signature below constitutes my acknowledgement that (1) I have read, understood and fully agree to the foregoing consent. (2) The proposed treatment has been satisfactorily explained to me and I have all the information which I desire. (3) I hereby give my consent and authorisation voluntarily and release you and your agents of any claims that I have or may have in the future in connection with the described treatment.*